The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada.

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.

En dépit des avancées importantes de la recherche médicale et des efforts en santé publique, il reste des lacunes dans les connaissances sur la santé cardiaque des femmes sur les plans de l'épidémiologie, du tableau clinique, de la prise en charge, des résultats, de l'éducation, de la recherche et des publications. Du point de vue historique, la cardiopathie a d'abord été perçue comme une maladie qui touchait les hommes et les individus de sexe masculin. De ce fait, la compréhension des risques particuliers et des symptômes qu'éprouvent les femmes est limitée. Ces lacunes dans les connaissances posent particulièrement problème puisqu'à l'échelle mondiale la cardiopathie est la cause principale de décès chez les femmes. Jusqu'à récemment, la recherche en cardiologie, notamment la recherche préclinique et clinique, ne portait pas sur le sexe et le genre. Le recrutement souvent limité aux participants masculins et aux individus dont l'identité de genre correspond au sexe masculin et l'absence d'analyses de données en fonction du sexe ou du genre ont eu pour conséquence un manque de données sur la façon dont les traitements et les interventions nuisent aux patientes féminines et aux individus dont l'identité de genre correspond au sexe féminin, et ce, de façon différente. Cette absence de données a mené à un traitement sous-optimal et à des limites de notre compréhension des mécanismes sous-jacents de la cardiopathie chez les femmes, et est directement reliée à nos connaissances limitées, et à nos lacunes en formation professionnelle et en éducation du public. Le fait que les femmes ne connaissent souvent pas leurs facteurs de risque de maladies du cœur ou les symptômes qu'elles peuvent éprouver entraîne des retards de diagnostic et de traitements. De plus, le fait que les prestataires de soins de santé ne reçoivent pas la formation adéquate pour poser le diagnostic et traiter la cardiopathie chez les femmes les mène à poser un mauvais diagnostic ou à ne pas traiter suffisamment. Pour pallier ces lacunes de connaissances, il faut une approche à plusieurs volets, qui porte notamment sur l'éducation et les changements dans les politiques, et qui repose sur la recherche fondée sur des données probantes. Dans ce chapitre, nous passons en revue l'état actuel de la recherche existante sur les maladies cardiovasculaires au Canada, plus particulièrement chez les femmes.

The association of maternal sugary beverage consumption during pregnancy and the early years with childhood sugary beverage consumption.

OBJECTIVES: A woman's food choices during pregnancy may be associated with her offspring's food choices. Several studies support an association between childhood sugary beverage (SB) consumption and poor cardiometabolic health. This study aimed to assess the association of maternal SB consumption during pregnancy and later, with her offspring's SB consumption in early infancy and childhood. METHODS: A total of 1945 women and 1595 children participating in 3 Canadian studies reported SB consumption during pregnancy, at 2 years of age, and/or at school age (5 to 8 years old). Mother and offspring SB intakes were self-reported by mothers. Multivariable linear regression analyses were conducted within each cohort and cohort data were combined using fixed effect meta-analyses. RESULTS: Maternal SB consumption during pregnancy was associated with higher offspring SB consumption at 2 years of age (standardized ß = 0.19 predicted change in the number of standard deviations of offspring SB intake for an increase of 1 standard deviation in maternal serving [95% CI: 0.16 to 0.22]). Concurrent maternal SB consumption was associated with higher offspring SB intake when children were aged 5 to 8 years (standardized ß= 0.25 [95% CI: 0.10 to 0.40]). CONCLUSION: Maternal SB consumption during pregnancy is associated with a marginally higher SB intake among their offspring at age 2, and concurrent maternal consumption is associated with a higher SB intake among school-aged offspring (5 to 8 years old). Future interventions tailored for pregnancy and early childrearing years to reduce SB intakes of mothers may reduce young children's SB intake.

RéSUMé: OBJECTIFS: Il peut y avoir un lien entre les choix alimentaires d'une femme pendant la grossesse et ceux de son enfant. Plusieurs études font état d'une association entre la consommation de boissons sucrées (BS) durant l'enfance et la mauvaise santé cardiométabolique. Notre étude visait à évaluer l'association entre la consommation de BS des mères pendant et après la grossesse et la consommation de BS de leurs enfants durant la petite enfance et l'enfance. MéTHODE: En tout, 1 945 femmes et 1 595 enfants participant à 3 études canadiennes ont fait état de leur consommation de BS pendant la grossesse, à l'âge de 2 ans et/ou à l'âge scolaire (5 à 8 ans). La consommation de BS des mères et des enfants a été déclarée par les mères. Des analyses de régression linéaire multivariée ont été menées dans chaque cohorte, et les données des cohortes ont été combinées à l'aide de méta-analyses à effets fixes. RéSULTATS: La consommation maternelle de BS pendant la grossesse était associée à une consommation de BS plus élevée chez les enfants à l'âge de 2 ans (le coefficient ß standardisé = 0,19 prédisait le changement du nombre d'écart-types de consommation de BS chez les enfants pour chaque hausse de 1 écart-type de la portion maternelle [IC de 95 % : 0,16 à 0,22]). La consommation maternelle concomitante de BS était associée à une consommation de BS plus élevée chez les enfants lorsqu'ils étaient âgés de 5 à 8 ans (coefficient ß standardisé = 0,25 [IC de 95 % : 0,10 à 0,40]). CONCLUSION: La consommation maternelle de BS pendant la grossesse est associée à une consommation de BS marginalement plus élevée chez l'enfant à l'âge de 2 ans, et la consommation maternelle concomitante est associée à une consommation de BS plus élevée chez l'enfant d'âge scolaire (5 à 8 ans). De futures interventions visant à réduire la consommation de BS des mères pendant la grossesse et durant les premières années où elles élèvent leurs enfants pourraient réduire la consommation de BS des jeunes enfants.

The genetic risk of gestational diabetes in South Asian women.

South Asian women are at increased risk of developing gestational diabetes mellitus (GDM). Few studies have investigated the genetic contributions to GDM risk. We investigated the association of a type 2 diabetes (T2D) polygenic risk score (PRS), on its own, and with GDM risk factors, on GDM-related traits using data from two birth cohorts in which South Asian women were enrolled during pregnancy. 837 and 4372 pregnant South Asian women from the SouTh Asian BiRth CohorT (START) and Born in Bradford (BiB) cohort studies underwent a 75-g glucose tolerance test. PRSs were derived using genome-wide association study results from an independent multi-ethnic study (~18% South Asians). Associations with fasting plasma glucose (FPG); 2 hr post-load glucose (2hG); area under the curve glucose; and GDM were tested using linear and logistic regressions. The population attributable fraction (PAF) of the PRS was calculated. Every 1 SD increase in the PRS was associated with a 0.085 mmol/L increase in FPG ([95% confidence interval, CI=0.07-0.10], p=2.85×10-20); 0.21 mmol/L increase in 2hG ([95% CI=0.16-0.26], p=5.49×10-16); and a 45% increase in the risk of GDM ([95% CI=32-60%], p=2.27×10-14), independent of parental history of diabetes and other GDM risk factors. PRS tertile 3 accounted for 12.5% of the population's GDM alone, and 21.7% when combined with family history. A few weak PRS and GDM risk factors interactions modulating FPG and GDM were observed. Taken together, these results show that a T2D PRS and family history of diabetes are strongly and independently associated with multiple GDM-related traits in women of South Asian descent, an effect that could be modulated by other environmental factors.

South Asian Youth as Vaccine Agents of Change (SAY-VAC): evaluation of a public health programme to mobilise and empower South Asian youth to foster COVID-19 vaccine-related evidence-based dialogue in the Greater Toronto and Hamilton Area, Canada.

OBJECTIVES: There have been substantial amounts of misinformation surrounding the importance, safety and effectiveness of the COVID-19 vaccine. The impacts of this misinformation may be augmented as they circulate among ethnic communities, who may concurrently face other barriers related to vaccine uptake and access. To combat some of the key sources of COVID-19 vaccine misinformation among the South Asian communities of the Greater Toronto and Hamilton Area (GTHA), an interdisciplinary team of researchers and marketing experts established the South Asian Youth as Vaccine Agents of Change (SAY-VAC) programme to support and empower South Asian youth to disseminate COVID-19 vaccine information. DESIGN: Cross-sectional and one-group pretest-post-test design. SETTING: GTHA. PARTICIPANTS: South Asian youth (18-29 years). INTERVENTION: The team partnered with grass-roots South Asian organisations to collaborate on shared objectives, curate key concerns, create video products regarding the COVID-19 vaccine that would resonate with the community, disseminate the products using established social media channels and evaluate the effectiveness of this effort. OUTCOMES: We assessed the change in self-reported knowledge about the COVID-19 vaccine and participant confidence to facilitate a conversation around the COVID-19 vaccine using pre-post surveys, after the implementation of the SAY-VAC programme. RESULTS: In total, 30 South Asian youth (median age=23.2 years) from the GTHA participated in the programme. After completing the SAY-VAC programme, participants reported an increase in their self-reported knowledge regarding the COVID-19 vaccine from 73.3% to 100.0% (p=0.005), and their self-reported confidence to have a conversation about the vaccine with their unvaccinated community members increased from 63.6% to 100.0% (p=0.002). Overall, 51.9% of the participants reported being able to positively affect an unvaccinated/community member's decision to get vaccinated. CONCLUSIONS: The SAY-VAC programme highlights the importance of community partnerships in developing and disseminating culturally responsive health communication strategies. A constant assessment of the evidence and utilisation of non-traditional avenues to engage the public are essential.

Seropositivity and risk factors for SARS-CoV-2 infection in a South Asian community in Ontario: a cross-sectional analysis of a prospective cohort study.

BACKGROUND: Early in the COVID-19 pandemic, the South Asian community in the Greater Toronto Area (GTA) was identified as having risk factors for exposure and specific barriers to accessing testing and reliable health information, rendering them particularly vulnerable to SARS-CoV-2 infection. We sought to investigate the burden of SARS-CoV-2 infection among South Asian people in the GTA, and to characterize the demographic characteristics, risk perceptions and trusted sources of health information in this group. METHODS: We conducted a cross-sectional analysis from the baseline assessment of participants in a prospective cohort study. Participants from the GTA were enrolled from Apr. 14 to July 28, 2021. Seropositivity for antispike and antinucleocapsid antibodies was determined from dried blood spots, and estimates of seropositivity were age and sex standardized to the South Asian population in Ontario. Demographic characteristics, risk perceptions and sources of COVID-19 information were collected via questionnaire and reported descriptively. RESULTS: Among the 916 South Asian participants enrolled (mean age 41 yr), the age- and sex-standardized seropositivity was 23.6% (95% confidence interval 20.8%-26.4%). Of the 693 respondents to the questionnaire, 228 (32.9%) identified as essential workers, and 125 (19.1%) reported living in a multigenerational household. A total of 288 (49.4%) perceived that they were at high COVID-19 risk owing to their geographic location, and 149 (34.3%) owing to their type of employment. The top 3 most trusted sources of information related to COVID-19 included health care providers and public health, traditional media sources and social media. INTERPRETATION: By the third wave of the COVID-19 pandemic, about one-quarter of a sample of South Asian individuals in Ontario had serologic evidence of prior SARS-CoV-2 infection. Insight into factors that put certain populations at risk can help future pandemic planning and disease control efforts.

Effects of lifestyle interventions on cardiovascular risk factors in South Asians: a systematic review and meta-analysis.

BACKGROUND: The cardiovascular disease (CVD) burden among South Asians is high. Lifestyle interventions have been effective in the primary prevention of CVD, but this has not been replicated, through a synthesis of randomised trials, in South Asians. METHODS: Four electronic databases (MEDLINE, Embase, CENTRAL and CINAHL), two clinical trial registries and references of included articles were searched through June 2022 (featuring ≥90% South Asian participants). Random-effects pairwise meta-analyses were performed, and heterogeneity was quantified with the I2 statistic. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to report on the quality of evidence (International Prospective Register of Systematic Reviews registration (PROSPERO). RESULTS: Thirty-five studies were included. Twelve tested diet and physical activity interventions; 18 tested diet alone; and 5 tested physical activity alone. All reported effects of the intervention(s) on at least one established risk factor for CVD, including blood pressure (systolic blood pressure (SBP), diastolic blood pressure (DBP) and blood lipids (high-density lipoprotein cholesterol (HDLc), low-density lipoprotein cholesterol (LDLc) or triglycerides). No trials reported clinical CVD. There is moderate-quality evidence that diet and physical activity interventions improve SBP (mean difference (MD) -2.72 mm Hg, 95% CI -4.11 to -1.33) and DBP (MD -1.53 mm Hg, 95% CI -2.57 to -0.48); high-quality to moderate-quality evidence that diet-only interventions improve DBP (MD -2.05 mm Hg, 95% CI -2.93 to -1.16) and blood lipids (triglycerides (MD -0.10 mmol/L, 95% CI -0.14 to -0.06) and LDLc (MD -0.19 mmol/L, 95% CI -0.32 to -0.06)); and moderate-quality evidence that physical activity-only interventions improve SBP (MD -9.7 mm Hg, 95% CI -11.05 to -8.35), DBP (MD -7.29 mm Hg, 95% CI -8.42 to -6.16) and HDLc (MD 0.08 mmol/L, 95% CI 0.04 to 0.11) compared with usual care. CONCLUSIONS: Lifestyle interventions improve blood pressure and blood lipid profiles in adult South Asians at risk of CVD. Tailored interventions should be used to modify cardiovascular risk factors in this at-risk group. PROSPERO REGISTRATION NUMBER: CRD42018090419.

Studies to Improve Perinatal Health through Diet and Lifestyle among South Asian Women Living in Canada: A Brief History and Future Research Directions.

South Asians (i.e., people who originate from India, Pakistan, Sri Lanka, Nepal, and Bangladesh) have higher cardiovascular disease rates than other populations, and these differences persist in their offspring. Nutrition is a critical lifestyle-related factor that influences fetal development, and infant and child health in early life. In high-income countries such as Canada, nutrition-related health risks arise primarily from overnutrition, most strikingly for obesity and associated non-communicable diseases. Evidence for developmental programming during fetal life underscores the critical influence of maternal diet on fetal growth and development, backed by several birth cohort studies including the Pune Maternal Nutrition Study, the South Asian Birth Cohort Study, and the Born in Bradford Study. Gestational diabetes mellitus is a strong risk factor for type 2 diabetes, future atherosclerosis and cardiovascular disease in the mother and increases the risk of type 2 diabetes in her offspring. Non-pharmacological trials to prevent gestational diabetes are few, often not randomized, and are heterogeneous with respect to design, and outcomes have not converged upon a single optimal prevention strategy. The aim of this review is to provide an understanding of the current knowledge around perinatal nutrition and gestational diabetes among the high-risk South Asian population as well as summarize our research activities investigating the role of culturally-tailored nutrition advice to South Asian women living in high-income settings such as Canada. In this paper, we describe these qualitative and quantitative studies, both completed and underway. We conclude with a description of the design of a randomized trial of a culturally tailored personalized nutrition intervention to reduce gestational glycaemia in South Asian women living in Canada and its implications.

Organizing a Mass Gathering Amidst a Rising COVID-19 Public Health Crisis: Lessons Learned From a Chinese Public Health Forum in Vancouver, BC.

Introduction The coronavirus disease 2019 (COVID-19) evolved from a rising public health concern to a pandemic over mere weeks. Before March 11, 2020, the Public Health Agency of Canada had not advised against any mass gatherings. Herein, we highlight practical precautions taken by event organizers to adapt to the rising public health threat from COVID-19 and maintain public safety when conducting a health forum for the Chinese community of Vancouver, British Columbia on February 22, 2020. Materials and Methods In the pre-forum phase, we advertised the availability of virtual conferencing for remote participation in the forum and also had an official communication from the Ministry of Health available regarding COVID-19 on our website. At the forum, we ensured that attendees sanitized their hands at registration and had access to sanitizers throughout the forum. Additionally, we provided translated health literature on COVID-19 to participants and had our health professional speakers address COVID-19-related questions. Results This year, 231 older Chinese adults attended the forum in-person, while 150 participated remotely. The total number of 381 participants compares well to previous iterations of the forum, with twice the amount of participants on average attending online than before. Of the participants who attended the forum, 89% suggested that the forum would be effective in improving their overall health and 87% cited the forum's utility in directing them to access community resources. None of the attendees had COVID-19 or are suspected to have contracted it at the forum. Conclusion Conducting a mass gathering during a crisis required closely following guidance from local public health authorities, constant and clear communication with attendees, and employing practical risk mitigation strategies.

Effects of Sahaj Samadhi meditation on heart rate variability and depressive symptoms in patients with late-life depression.

BACKGROUND: Late-life depression (LLD) is a disabling disorder and antidepressants are ineffective in as many as 60% of cases. Converging evidence shows a strong correlation between LLD and subsequent risk of cardiovascular disease. There is a need for new, well-tolerated, non-pharmacological augmentation interventions that can treat depressive symptoms as well as improve heart rate variability (HRV), an important prognostic marker for development of subsequent cardiovascular disease. Meditation-based techniques are of interest based on positive findings in other samples.AimsWe aimed to assess the efficacy of Sahaj Samadhi meditation (SSM), an underevaluated, standardised and manualised meditation intervention, on HRV and depressive symptoms. METHOD: Eighty-three men and women aged 60-85 years, with mild to moderate depression and receiving treatment as usual (TAU) were randomised to either the SSM or TAU arm. Those allocated to SSM attended 4 consecutive days of group meditation training, using personalised mantras followed by 11 weekly reinforcement sessions. HRV and Hamilton Rating Scale for Depression (HRSD; 17-item) score were measured at baseline and 12 weeks. RESULTS: All time and frequency domain measures of HRV did not significantly change in either arm. However, there was significant improvement in the SSM arm, compared with TAU, on the HRSD (difference in mean, 2.66; 95% CI 0.26-5.05; P = 0.03). CONCLUSIONS: Compared with TAU, SSM is associated with improvements in depressive symptoms but does not significantly improve HRV in patients with LLD. These results need to be replicated in subsequent studies incorporating a group-based, active control arm.Declaration of interestR.I.N. is the Director of Research and Health Promotion for the Art of Living Foundation, Canada and supervised the staff providing Sahaj Samadhi meditation. S.R. has received research funding from Satellite Healthcare for a mindfulness meditation trial in patients on haemodialysis. The remaining authors report no financial or other relationship relevant to the subject of this article.